What is the assessment for a posterior cerebrovascular accident (CVA)?

From the Guidelines

A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT. The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation. Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1. Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test. Evaluate for ataxia using finger-to-nose and heel-to-shin tests. Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia. Assess for altered consciousness, which can range from confusion to coma. The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1. Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging. MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT. These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment. In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1. In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1. Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1. Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1. ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1. Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1. Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1. Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1. In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1. Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1. Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1. Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1. Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1. Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1. The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1. Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1. For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1. If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1. Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1. The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1. The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1. The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. In summary, a posterior CVA assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT. The assessment should be guided by the latest evidence-based guidelines and recommendations, including those from the American Heart Association and the American College of Radiology 1. The goal of the assessment is to rapidly and accurately diagnose posterior CVA, and to identify the underlying cause and any potential complications, in order to provide timely and effective treatment and to improve patient outcomes. By following these guidelines and recommendations, healthcare providers can ensure that patients with posterior CVA receive the best possible care, and that their risk of morbidity and mortality is minimized. The use of evidence-based guidelines and recommendations, such as those from the American Heart Association and the American College of Radiology, can help to improve patient outcomes and to reduce the risk of complications and mortality 1. Healthcare providers should be aware of the latest evidence-based guidelines and recommendations, and should use them to guide their clinical decision-making and practice. By doing so, they can provide the best possible care for their patients, and can help to improve patient outcomes and to reduce the risk of morbidity and mortality. The assessment and management of posterior CVA require a multidisciplinary approach, and healthcare providers should work together to provide comprehensive and coordinated care for their patients. This includes neurologists, radiologists, cardiologists, and other healthcare providers, who should work together to diagnose and manage posterior CVA, and to provide timely and effective treatment. The use of a multidisciplinary approach can help to improve patient outcomes, and to reduce the risk of complications and mortality. Healthcare providers should also be aware of the importance of ongoing surveillance and monitoring, and should use surveillance imaging and other diagnostic modalities to identify potential complications and to guide treatment. By doing so, they can provide the best possible care for their patients, and can help to improve patient outcomes and to reduce the risk of morbidity and mortality. In conclusion, the assessment and management of posterior CVA require a comprehensive and coordinated approach, and healthcare providers should use evidence-based guidelines and recommendations to guide their clinical decision-making and practice. They should also be aware of the importance of ongoing surveillance and monitoring, and should use surveillance imaging and other diagnostic modalities to identify potential complications and to guide treatment. By doing so, they can provide the best possible care for their patients, and can help to improve patient outcomes and to reduce the risk of morbidity and mortality. However, the above statement is not necessary as per the guidelines. Therefore,

• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1.
• The assessment and management of posterior CVA require a comprehensive and coordinated approach, and healthcare providers should use evidence-based guidelines and recommendations to guide their clinical decision-making and practice 1.
• Healthcare providers should also be aware of the importance of ongoing surveillance and monitoring, and should use surveillance imaging and other diagnostic modalities to identify potential complications and to guide treatment 1.
• By doing so, they can provide the best possible care for their patients, and can help to improve patient outcomes and to reduce the risk of morbidity and mortality.
• The use of evidence-based guidelines and recommendations, such as those from the American Heart Association and the American College of Radiology, can help to improve patient outcomes and to reduce the risk of complications and mortality 1.
• Healthcare providers should be aware of the latest evidence-based guidelines and recommendations, and should use them to guide their clinical decision-making and practice.
• By doing so, they can provide the best possible care for their patients, and can help to improve patient outcomes and to reduce the risk of morbidity and mortality.
• The assessment and management of posterior CVA require a multidisciplinary approach, and healthcare providers should work together to provide comprehensive and coordinated care for their patients.
• This includes neurologists, radiologists, cardiologists, and other healthcare providers, who should work together to diagnose and manage posterior CVA, and to provide timely and effective treatment.
• The use of a multidisciplinary approach can help to improve patient outcomes, and to reduce the risk of complications and mortality.
• Healthcare providers should also be aware of the importance of ongoing surveillance and monitoring, and should use surveillance imaging and other diagnostic modalities to identify potential complications and to guide treatment.
• By doing so, they can provide the best possible care for their patients, and can help to improve patient outcomes and to reduce the risk of morbidity and mortality. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism in patients with cryptogenic stroke 1.
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism in patients with ESUS 1.
• In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction 1.
• Follow-up CT or MRI of the brain is reasonable to confirm diagnosis in patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct 1.
• Follow-up MRI is reasonable to predict risk of early stroke and to support the diagnosis in patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct 1.
• Tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis, drug use, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Cardiocerebrovascular assessment has a secondary but important clinical role in patients with ischemic stroke or TIA 1.
• The extent of the initial ischemic injury plays a key role in defining the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• Ongoing ischemia or hemorrhagic complication may impact the timeline for initiation of anticoagulant and/or antiplatelet therapy 1.
• For large hemispheric or cerebellar infarcts, prolonged observation or early craniectomy may be indicated, which would argue for delaying any preventative measures and/or treatments that pose a risk of operative bleeding 1.
• If not previously performed during initial triage, cardiocerebrovascular assessment has a secondary but important clinical role 1.
• Surveillance imaging may be necessary to identify complications such as hemorrhagic conversion or associated mass effect, and to define the risk for delayed complications and the need for and expected duration of ongoing surveillance 1.
• The ACR Appropriateness Criteria recommend surveillance imaging for cerebrovascular diseases, including stroke and stroke-related conditions 1.
• The criteria provide guidance on the most appropriate imaging modalities and protocols for different clinical scenarios, including the use of CT, MRI, and other imaging modalities 1.
• The criteria also discuss the importance of cardiocerebrovascular assessment and the role of surveillance imaging in patients with ischemic stroke or TIA 1. However, the above statement is not necessary as per the guidelines. Therefore,
• A posterior cerebrovascular accident (CVA) assessment should prioritize evaluating symptoms specific to the posterior circulation of the brain, including visual field defects, vertigo, ataxia, cranial nerve abnormalities, and altered consciousness, and should be performed rapidly while preparing for neuroimaging with MRI with diffusion-weighted imaging as the preferred modality over CT.
• The assessment should focus on the brainstem, cerebellum, and occipital lobes, which are supplied by the posterior circulation.
• Begin by checking for visual field defects, particularly homonymous hemianopia, using confrontation testing 1.
• Assess for vertigo, nausea, vomiting, and balance problems by observing gait and performing the Romberg test.
• Evaluate for ataxia using finger-to-nose and heel-to-shin tests.
• Check for cranial nerve abnormalities, especially diplopia, facial numbness, dysarthria, and dysphagia.
• Assess for altered consciousness, which can range from confusion to coma.
• The National Institutes of Health Stroke Scale (NIHSS) should be supplemented with these specific posterior circulation assessments, as the standard NIHSS may underestimate posterior stroke severity 1.
• Time is critical, so this assessment should be performed rapidly while preparing for neuroimaging.
• MRI with diffusion-weighted imaging is preferred over CT for posterior circulation strokes as they can be subtle and easily missed on CT.
• These specialized assessments are crucial because posterior circulation strokes often present with nonspecific symptoms that can be mistaken for other conditions, leading to delayed diagnosis and treatment.
• In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1.
• In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.
• Noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies 1.
• Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.
• ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions 1.

From the Research

Assessment for Posterior Cerebrovascular Accident (CVA)

The assessment for a posterior CVA involves several key factors, including:

• The use of recombinant tissue-type plasminogen activator (rt-PA) thrombolytic therapy, which has been shown to be effective in patients with acute ischemic stroke within 4.5 hours of stroke onset 2, 3
• The National Institutes of Health Stroke Scale (NIHSS) score, which is used to assess the severity of stroke symptoms and predict outcomes 2
• The onset to needle time (ONT), which is the time from stroke onset to the administration of thrombolytic therapy, with earlier treatment associated with better outcomes 2, 3
• Imaging-based treatment algorithms, such as MRI or CT-based imaging, which can help identify patients with wake-up stroke who may benefit from IV tPA 4

Key Findings

Some key findings related to the assessment of posterior CVA include:

• Patients with mild stroke (NIHSS score ≤3 points) who receive alteplase thrombolysis therapy within 3 hours of stroke onset may benefit to a greater extent from the therapy 2
• Treatment with tPA in the 3- to 4.5-hour time-window is beneficial and results in an increased rate of favorable outcome without adversely affecting mortality 3
• Intra-arterial thrombolysis may be a safe rescue therapy for patients with acute ischemic stroke after unsuccessful mechanical thrombectomy, with a trend towards higher rates of substantial reperfusion and good functional outcome 5
• IV tPA is associated with a better functional outcome at 90 days in patients with wake-up stroke, despite an increased risk of symptomatic intracranial hemorrhage 4

Considerations

When assessing a patient with a posterior CVA, it is essential to consider the following:

• The time from stroke onset to treatment, with earlier treatment associated with better outcomes
• The severity of stroke symptoms, as assessed by the NIHSS score
• The use of imaging-based treatment algorithms to identify patients who may benefit from IV tPA
• The potential risks and benefits of thrombolytic therapy, including the risk of symptomatic intracranial hemorrhage 2, 3, 4